Provider Demographics
NPI:1104941095
Name:CLARK'S ORTHOPEDIC & MEDICAL
Entity type:Organization
Organization Name:CLARK'S ORTHOPEDIC & MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:406-452-8428
Mailing Address - Street 1:816 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-2136
Mailing Address - Country:US
Mailing Address - Phone:406-452-8428
Mailing Address - Fax:406-452-8741
Practice Address - Street 1:2808 BILLINGS AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-9768
Practice Address - Country:US
Practice Address - Phone:406-442-6069
Practice Address - Fax:406-442-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0631176Medicaid
MT0631176Medicaid